Andrea Swartzendruber

Update and Overview of Practical Epidemiologic Aspects of HIV/AIDS among Injection Drug Users in the United States

In a changing public health landscape in which local, state, and federal agencies must confront threats of bioterrorism, emerging infections, and numerous chronic diseases, transmission of HIV among injection drug users (IDUs) continues to be an important public health issue and one of the driving forces behind the HIV epidemic. Using a computerized MEDLINE search of published articles from January 1981 through October 2005, we conducted a literature review of practical epidemiologic aspects of HIV/AIDS among IDUs in the United States. Although recent trends indicate a decline in the proportion of newly diagnosed HIV infections associated with injection drug use, drug-use behaviors overall still account for 32% of new HIV diagnoses. Factors in addition to syringe sharing contribute to HIV transmission among IDUs: risky sexual behaviors, sharing of drug preparation equipment and drug solutions, and contextual and social factors. Promising approaches for HIV prevention include rapid HIV testing, office-based substance abuse treatment, behavioral interventions, improved communication about syringe exchange programs, and case management. HIV among IDUs continues to be an important public health problem in the 21st century. It is imperative that public health agencies continue to monitor and combat the HIV epidemic among IDUs to ensure that hard-won gains will not be eroded.

Efficacy of an HIV/STI Sexual Risk-Reduction Intervention for African American Adolescent Girls in Juvenile Detention Centers: A Randomized Controlled Trial

Few HIV/STI interventions exist for African American adolescent girls in juvenile detention. The objective was to evaluate the efficacy of an intervention to reduce incident STIs, improve HIV-preventive behaviors, and enhance psychosocial outcomes. We conducted a randomized controlled trial among African American adolescent girls (13–17 years, N = 188) in juvenile detention from March 2011 to May 2012. Assessments occurred at baseline and 3- and 6-months post-randomization and included: audio computer-assisted self-interview, condom skills assessment, and self-collected vaginal swab to detect Chlamydia and gonorrhea. The Imara intervention included three individual-level sessions and four phone sessions; expedited partner therapy was offered to STI-positive adolescents. The comparison group received the usual care provided by the detention center: STI testing, treatment, and counseling. At the 6-month assessment (3-months post-intervention), Imara participants reported higher condom use self-efficacy (p < 0.001), HIV/STI knowledge (p < 0.001), and condom use skills (p < 0.001) compared to control participants. No significant differences were observed between trial conditions in incident Chlamydia or gonorrhea infections, condom use, or number of vaginal sex partners. Imara for detained African American adolescent girls can improve condom use skills and psychosocial outcomes; however, a critical need for interventions to reduce sexual risk remains.

It takes 2: Partner attributes associated with sexually transmitted infections among adolescents

Objectives The aims of this study were to identify partner attributes associated with sexually transmitted infections (STIs) among adolescents and to summarize implications for research and prevention. Design The design of this study was systematic review. Methods We identified peer-reviewed studies published in 1990 through 2010 that assessed 1 or more partner attributes in relation to a biologically confirmed STI among adolescents (15–24 years) by searching MEDLINE and included articles. Studies that included adolescents but more than 50% of the sample or with mean or median age of 25 years or greater were excluded. Results Sixty-four studies met the eligibility criteria; 61% were conducted in high-income countries; 80% were cross sectional; and 91% enrolled females and 42% enrolled males. There was no standard “partner” definition. Partner attributes assessed most frequently included the following: age, race/ethnicity, multiple sex partners, and STI symptoms. Older partners were associated with prevalent STIs but largely unrelated to incidence. Black race was associated with STIs but not uniformly. Partners with multiple partners and STI symptoms seem to be associated with STIs predominantly among females. Although significant associations were reported, weaker evidence exists for the following: other partner sociodemographics, sexual and other behaviors (sexual concurrency, intimate partner violence, substance use, travel), and STI history. There were no apparent differences by STI. Conclusions Partner attributes are independently associated with STIs among male and female adolescents worldwide. These findings reinforce the importance of assessing partner attributes when determining STI risk. Prevention efforts should continue to promote and address barriers to condom use. Increased efforts are needed to screen and treat STIs and reduce risky behavior among men. A standard partner definition would facilitate the interpretation of findings in future studies.

Long-Acting Reversible Contraception and Condom Use Among Female US High School Students: Implications for Sexually Transmitted Infection Prevention.

IMPORTANCE Long-acting reversible contraception (LARC), specifically intrauterine devices and implants, offers an unprecedented opportunity to reduce unintended pregnancies among adolescents because it is highly effective even with typical use. However, adolescent LARC users may be less likely to use condoms for preventing sexually transmitted infections compared with users of moderately effective contraceptive methods (ie, oral, Depo-Provera injection, patch, and ring contraceptives). OBJECTIVE To compare condom use between sexually active female LARC users and users of moderately effective contraceptive methods. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis using data from the 2013 national Youth Risk Behavior Survey, a nationally representative sample of US high school students in grades 9 through 12. Descriptive analyses were conducted among sexually active female students (n = 2288); logistic regression analyses were restricted to sexually active female users of LARC and moderately effective contraception (n = 619). The analyses were conducted in July and August 2015. MAIN OUTCOMES AND MEASURES Contraceptive method at last sexual intercourse was assessed by 1 item-respondents could select birth control pills; condoms; an intrauterine device or implant; injection, patch, or ring; withdrawal or other method; or not sure. A separate item asked whether respondents used a condom at last sexual intercourse. We created an indicator variable to distinguish those reporting use of (1) LARC (intrauterine device or implant), (2) oral contraceptives, and (3) Depo-Provera, patch, or ring. RESULTS Among the 2288 sexually active female participants (56.7% white; 33.6% in 12th grade), 1.8% used LARC; 5.7% used Depo-Provera, patch, or ring; 22.4% used oral contraceptives; 40.8% used condoms; 11.8% used withdrawal or other method; 15.7% used no contraceptive method; and 1.9% were not sure. In adjusted analyses, LARC users were about 60% less likely to use condoms compared with oral contraceptive users (adjusted prevalence ratio [aPR], 0.42; 95% CI, 0.21-0.84). No significant differences in condom use were observed between LARC users and Depo-Provera injection, patch, or ring users (aPR, 0.57; 95% CI, 0.26-1.25). The LARC users were more than twice as likely to have 2 or more recent sexual partners compared with oral contraceptive users (aPR, 2.61; 95% CI, 1.75-3.90) and Depo-Provera, patch, or ring users (aPR, 2.58; 95% CI, 1.17-5.67). CONCLUSIONS AND RELEVANCE Observed differences in condom use may reflect motivations to use condoms for backup pregnancy prevention. Users of highly effective LARC methods may no longer perceive a need for condoms even if they have multiple sexual partners, which places them at risk for sexually transmitted infections. As uptake of LARC increases among adolescents, a clear need exists to incorporate messages about condom use specifically for sexually transmitted infection prevention.

Application of audio computer-assisted self-interviews to collect self-reported health data: an overview.

For assessment of sensitive health behaviors (e.g., sexual behavior, violent behaviors, substance use), research is typically limited to an examination of self-reports of past behavior. Audio computer-assisted self-interviews (ACASI) may enhance the validity of self-report data in research and clinical settings by reducing measurement bias. This paper provides an introduction to ACASI for collection of self-reported health data. The potential benefits and cost-effectiveness of ACASI use in research and clinical settings are reviewed. We then review the theoretical underpinnings that may underlie differential reporting of health behaviors between assessment modalities. Next, we highlight studies that have investigated differences in self-reported health behaviors between assessment modalities. Lastly, we summarize potential applications of ACASI assessments within clinical settings.

Introduction of rapid syphilis testing in antenatal care: A systematic review of the impact on HIV and syphilis testing uptake and coverage

Global guidelines recommend universal syphilis and HIV screening for pregnant women. Rapid syphilis testing (RST) may contribute toward achievement of universal screening.

Interventions to Reduce Alcohol Use among HIV-Infected Individuals: A Review and Critique of the Literature

Alcohol use disorders are common among HIV-infected individuals and are associated with adverse physiological complications and increased engagement in other health risk behaviors. This paper provides a review and critique of interventions to reduce alcohol use among HIV-infected individuals, including a: (a) synthesis of core intervention components and trial designs; (b) summary of intervention efficacy to reduce alcohol use outcomes; and (c) methodological critique and guidance for future research. We reviewed 14 behavioral interventions that reported on alcohol use outcomes among HIV-infected individuals. Findings were mixed for intervention efficacy to reduce alcohol frequency and quantity. There was limited evidence that interventions reduced binge drinking frequency or alcohol abuse or dependence symptoms. Despite the prevalence of disordered alcohol use among HIV-infected individuals, there is lack of efficacious intervention approaches. Efficacious intervention approaches to reduce alcohol use among HIV-infected individuals are urgently needed.

Sexually transmitted infections, sexual risk behavior, and intimate partner violence among African American adolescent females with a male sex partner recently released from incarceration.

PURPOSE Social networks directly and indirectly influence sexually transmitted infections (STIs) risk. The objective was to explore associations between sex with a male recently released from incarceration and sexual risk and intimate partner violence (IPV) among African American adolescent females. METHODS Sociodemographic, psychosocial, and sexual behavior data were collected at baseline, 6, and 12 months from African American females, aged 15-21 years, participating in an HIV/STI prevention trial. Among 653 participants with ≥1 follow-up assessments, generalized estimating equations tested associations during follow-up between having a recently released partner and STI acquisition, sexual risk behaviors, and IPV, adjusting for age, treatment assignment, and corresponding baseline measure. RESULTS Eighty-three (13.6%) participants had a recently released partner at 6 months and 56 (9.3%) at 12 months. Participants with a recently released partner were more likely to have the following: vaginal (adjusted odds ratio [AOR]: 5.48), anal (AOR: 2.43), and oral (AOR: 1.51) sex, a casual partner (AOR: 1.66), sex while high/drunk (AOR: 1.57) or with a high/drunk partner (AOR: 2.27); use condoms inconsistently (AOR: .58); acquire Chlamydia (AOR: 1.80), and experience emotional (AOR: 4.09), physical (AOR: 2.59), or sexual abuse (AOR: 4.10) by a boyfriend. They had a greater number of sex partners, lower partner communication and refusal self-efficacy, were high/drunk during sex more frequently, and used condoms during oral sex less frequently. CONCLUSIONS A recently released sex partner is associated with sexual risk and IPV among African American adolescent females. Prevention programs should inform adolescents about potential risks associated with recently released partners as well as provide adolescents with skills to establish and maintain healthy sexual relationships.

Correlates of incident Trichomonas vaginalis infections among African American female adolescents.

Background Trichomonas vaginalis is the most common curable sexually transmitted infection associated with adverse reproductive health and pregnancy outcomes and may amplify HIV transmission. The objective was to identify correlates of incident T. vaginalis infections among African American adolescent girls. Methods Data were collected via audio computer-assisted self-interviews at baseline and every 6 months for 18 months from 701 African American girls (14–20 years) in an HIV prevention trial. At each assessment, self-collected vaginal swabs were assayed for T. vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae. Generalized estimating equations assessed associations between incident T. vaginalis infection and sociodemographic characteristics, substance use, partner-level factors, sexual risk behaviors, douching, and other sexually transmitted infections. Results Of 605 (86.3%) participants who completed at least 1 follow-up assessment, an incident T. vaginalis infection was detected among 20.0% (n = 121). Factors associated with incident infection in adjusted analysis included the following: cigarette smoking (adjusted odds ratio [AOR], 1.66; 95% confidence interval [CI], 1.04–2.64), using alcohol on an increasing number of days in the past 3 months (AOR, 1.02; 95% CI, 1.00–1.04), acquisition of C. trachomatis (AOR, 2.27; 95% CI, 1.40–3.69) or N. gonorrhoeae (AOR, 5.71; 95% CI, 2.97–11.02), and T. vaginalis infection at the previous assessment (AOR, 3.16; 95% CI, 1.96–5.07). Conclusions Incident T. vaginalis infections were common. Strategies to reduce infection rates among this population may include improving partner notification and treatment services. The benefits of rescreening, screening adolescents screened for or infected with C. trachomatis or N. gonorrhoeae, and associations between substance use and T. vaginalis acquisition warrant further investigation.

Improving the Validity of Self-reported Sexual Behavior: No Easy Answers

Accurate measurement of sexual risk behavior is essential to understanding sexually transmitted infection (STI) transmission dynamics and measuring the effects of sexual risk-reduction interventions. Historically, sexual behavior research has been typically limited to an examination of self-report of past behavior. However, challenges in obtaining accurate measurements of self-reported sexual behavior are well-documented. Indeed, adolescents’ self-reported sex behavior is sometimes confusing, inconsistent and, at times, contradictory. In this issue, Anderson and colleagues report on the effectiveness of two types of counseling messages to avoid unprotected vaginal sex during a brief treatment period for curable STIs. Specifically, the authors report on the effectiveness of either abstinence only or abstinence combined with condom use promotion counseling messages. While there are many aspects of the well-designed and implemented study worthy of additional comment, we focus on one, validity of self-reported sex. This study highlights strategies to reduce potential sources of bias in the measurement of sexual risk behaviors, and it also highlights the need for additional research to improve the validity of self-reported behavior. Anderson and colleagues used several procedures to minimize potential sources of bias in the measurement of unprotected sex during the treatment period. Threats to the validity of self-reported measures of unprotected sex include social desirability bias, recall bias, cognitive demands associated with recalling past behaviors, lack of awareness of condom errors and poor comprehension of survey questions. Motivational biases may be particularly pertinent to reporting of sensitive health behaviors, where it is commonly assumed that individuals underreport risk behaviors because of the sensitive, personal, and sometimes stigmatizing nature of such behaviors.1–3 In turn, motivational biases may lead individuals to distort their self-reported behavior to avoid shame or embarrassment or to appear in a more favorable light. 1,2 In the study conducted by Anderson and colleagues, the authors assessed participants’ self-reported sexual behaviors via a face-to-face interview, an assessment approach typically used in clinical venues. In addition to self-reported behavior, the authors collected vaginal swabs tested for prostate-specific antigen (PSA). The authors observed that approximately 10% of participants, overall, had biologic evidence of recent unprotected intercourse detected at the 6-day follow-up visit. The proportion of women with PSA detected was slightly higher in the abstinence-plus-condom group (11.9%) compared to the abstinence-only group (8.4%) although the difference was not statistically significant (RD = 3.5; 95% CI −3.5 to10.5). While concerning, particularly given that women are being treated for an STI and the period of assessment is brief (6 days), this may be an underestimate of sexual intercourse. The PSA detection window is only 48 hours, thus, women may have had unprotected vaginal sex beyond this detection window would not be identified as PSA-positive. Moreover, an estimated 71% of women exposed to semen will test negative for PSA by 24 hours. Furthermore, use of PSA does account for the proportion of women who may have only engaged in anal intercourse or may have substituted anal intercourse for vaginal intercourse during the treatment period. Thus, the observed PSA rate of 10% should be interpreted as the lower bound of the frequency of sexual intercourse during the treatment period. While the “true” proportion of women engaging in sexual intercourse is undetermined, it is safe to say that it may be substantially higher than observed. This finding is cause for concern and suggests that more intensive interventions are needed to modify womens sexual behavior.4 While PSA testing provided a useful complement to self-reported behavior in this study it could not substitute for the collection of self-reported data given PSA’s narrow detection window. The investigators, well aware of this limitation, discussed other potential biomarkers, such as Y-chromosome detection using a PCR assay; however, this test also had limitations in the context of this study as the detection window is too broad, detecting exposure to Y-chromosome that occurred beyond the 6-day treatment period, overestimating the proportion of women having unprotected vaginal intercourse. Furthermore, biomarkers such as PSA, Y-chromosome or spermatozoa detection also have other potential limitations, including cost, equipment needed to conduct assays, and applicability only among females. Other potential biomarkers, including incident STIs or pregnancy, also have inherent limitations given that these events do not occur after every unprotected sex act. Despite potential limitations, biomarkers of sexual behavior are useful and are recommended, when feasible, rather than relying solely on self-reported sexual behavior, given documented discrepancies between biologic data and self-reported sexual behavior.5–8 For example, >10% of adolescents who tested positive for an STI in a nationally-representative survey self-reported abstinence in the prior 12 months.6 Similarly, approximately 17% of adolescents from four U.S. cities with a laboratory-confirmed STI endorsed lifetime or recent abstinence from vaginal sex.5 Anderson and colleagues also attempted to reduce bias by obtaining consent to conduct PSA testing following collection of biologic specimens. The aim was to reduce the likelihood that participants would modify reporting of their behavior as a result of prior knowledge of PSA testing. Although the investigators did not present whether the differences were statistically significant, the proportion of women testing PSA-positive was greater than the proportion who endorsed recent unprotected sex, suggesting room to improve self-report of even very recent (i.e., within 2 days) sexual behavior. Discrepancies between self-reported behavior and biomarkers of sexual behavior are not randomly distributed. Several studies have identified factors associated with discrepancies between self-report and biologic data.5,9 Factors have included perceptions of peer norms, STI knowledge, HIV status, age, and race/ethnicity, among other factors.5,9 Recommendations to improve the validity of self-reported sexual behavior have been suggested and include techniques to improve recall (providing anchor dates, use of timeline-followback calendars and recall of memorable events during the reporting period, etc.), self-completed assessments, such as audio computer-assisted self-interviews (ACASI) to reduce socially desirable responding, use of language that is easily understood, placing the burden of denial on the participant (e.g., asking “how many times” rather than “if” a behavior occurred), providing confidentiality assurances, stressing the importance of accurate reporting for the development of programs that may benefit others, and including validity checks within assessments.3,5 While ACASI is widely thought to reduce socially desirable responding, we are aware of only study which compared the validity of ACASI and face-to-face interview data in relation to semen exposure, and that study observed no difference by interview modality.7 There is a clear, cogent and compelling need to improve the validity of self-reported sexual behavior. Additional observational research to identify reasons and motivations for less than accurate self-reported behavior would be useful. Intervention research to test strategies designed to improve the validity of self-reported sexual behavior are also needed. For example, self-report assessments could be designed to address misconceptions about sexual content and reduce potential discomfort or difficulty responding to sexual behavior questions. Additional strategies could address respondents’ knowledge gaps regarding sexual health and reduce their tendency to respond in a socially desirable fashion to avoid embarrassment or discomfort. The use of validity checks of self-reported sexual behaviors both within and across multiple assessments may also improve data quality. Strategies should also be employed to stress the importance of accurate reporting throughout the survey (e.g., in questionnaire instructions) and provide repeated information regarding how data will be utilized (e.g., analyzing data across participants rather than examining individual responses). Ultimately, use of sexual activity biological markers combined with strategies to improve the validity of self-reported of sexual behavior data will improve researchers’ abilities to accurately measure sexual behavior, STI transmission dynamics and the efficacy of STI prevention interventions.